J-Pouch Complications

Many of you already know that I am going through a series on J-Pouches this month in honor of my 2 years since takedown! See my previous posts: The History of the J-Pouch, What is a J-Pouch, and Two Years Since Takedown.

Although I would consider my own experience with a J-Pouch a success, I know my story is not everyone’s story. Every treatment for IBD has potential complications, and therefore I am remiss if I do not address them. So in this week’s topic I present you with potential complications of the J-Pouch.

Drs. Gorgun & Remzi – 2004

A study conducted by a group of doctors in 2004 who looked at the complications that come with ileoanal pouches. There are multiple possible complications that come with having a J-Pouch, however Drs. Gorgun and Remzi conclude that most studies on the topic of complications are positive.

“Most series in the literature demonstrate an acceptable complication rate with good-to-excellent functional and quality of life results,” they write. “Surgical experience, peri- and postoperative care, and proper competent intervention of complications affect surgical outcome and patient satisfaction.”

This is encouraging for many who are considering life with a J-Pouch. There many stories on the internet about the failure of the J-Pouch. A lot of blogs out there offer support for people with failed J-Pouches. And that’s GREAT! You need to hear the bad stories. You need to hear the good stories, too, so you can make an informed decision.

Because of all the bad stories floating around out there, I believe it is important to share my own experience. This is one reason why I blog. And as Sara Ringer has stated in the video that encouraged me to take the plunge, “…the majority of [J-Pouchers] are doing fine, and the reason that you do not hear from them […] is because they’re not out there writing to the internet saying ‘I love my J-Pouch!’ They’re out there living their lives.”

So, with all that said, I’d like you share with you some of the most common complications that come from getting a J-Pouch…

Early Complications

Sepsis
According to Drs. Gorgun and Remzi, the most serious of the early J-Pouch complications is Pelvic Sepsis. Their findings conclude the complication rate at anywhere between 5-24% of patients. Things that contribute to this complication are suture line leaks or bacterial contamination during the operation. Other risks include malnutrition, prolonged steroid use and blood problems.

Things to look for:
Fever
Perineal Pain
Purulent Discharge
Leukocytosis (high white blood cells)

Some studies show that having the procedure done in one stage as opposed to two or three stages makes pelvic sepsis more likely. Especially when high doses of steroids are in use for extended periods of time. Steroids negatively affect wound healing and increase the likeliness of infections. While I never had sepsis of any kind, I did develop three abscesses in my incision.

WARNING: Your discretion is advised. This photo is extremely graphic of a medical nature, but if you want to see my first and biggest abscess wound, you can click here.

Leaks
In the same study, Drs. Remzi and Gorgun find that the overall leak rate is between 5-18%. Leaks can occur anywhere that cutting/sewing/stapling has been conducted. This includes where the pouch is attached at the anus (or the apex of the J-Pouch), the tip (or top) of the J-Pouch or even in the middle of the J-Pouch where the afferent and efferent limbs of the J-Pouch meet (Click here to see J-Pouch Anatomy).

Those who were at greater risks for leaks are:
Elderly Patients
Patients on Corticosteroids
Males

As far as symptoms for leaks, the study states that patients may be asymptomatic “sinuses.” These are usually diagnosed during the takedown of the ileostomy and by putting off the closure of the ileostomy, most leaks will resolve themselves. In the case of leaks that don’t resolve themselves, the surgeon can suture or staple the J-Pouch. Persistent leaks may suggest misdiagnosed Crohn’s Disease.

Small Bowel Obstructions
People who undergo a multiple stage operation as opposed to a one stage operation are at a higher risk for a small bowel obstruction. Around 15-44% of patients will experience a small bowel obstruction (SBO) but only 5-20% of them will require surgical treatment. Some things that contribute to partial or complete SBO are postoperative adhesions (sort of like unusual, internal scar tissue), volvulus (an abnormal twisting of the bowels), internal herniation, or twisting of the ileostomy.

In addition, the study also finds that people who have their J-Pouch surgery done in one stage have only a 5% risk of SBO that require surgical intervention. Drs. Remzi and Gorgun also state that most of the obstructions occurred at the closing of the ileostomy. There are some biodegradable products available that help reduce adhesions and scarring, but as medical professional and fellow j-poucher, Shelly, says, “…the issue is, putting any foreign body in will increase the risk of inflammation, adhesions, strictures and/or fistulas.” She also states that, “if [the biodegradable products] work the way we hope, that would be great! If they don’t, that’s very bad news.”

Pouch Bleeding
According to a study, it is reported that about 3.8% of patients experience pouch bleeding. The reason for pouch bleeding either comes from the suture line or the lack of blood supply to the J-Pouch. There are only a few instances that operative treatment may be necessary to correct any postoperative bleeding, but most can be treated by applying saline and adrenaline. Others may be treated with iced saline and saline with epinephrine enemas.

I have actually found that if I eat something bothersome or if my J-Pouch is particularly overactive, I will find blood on the toilet paper. However: this is not like the blood that I found with ulcerative colitis. It appears as though this blood only comes when my bottom gets irritated. It usually resolves itself with Calmoseptine in a few days.

Late Complications

Pouchitis
According to many studies and patients, pouchitis is the most common complication following the J-Pouch surgery. Pouchitis can be acute (short-lived) or chronic (ongoing). Pouchitis is basically inflammation in the J-Pouch.

Symptoms to look for are:

Increased Frequency
Urgency
Cramping
Abdominal Pain
Bright Red Bleeding
Incontinence
Diarrhea
Fever

In addition to those listed above, you might also experience extra intestinal manifestations of IBD such as:

Arthritis
Iritis (Inflammation of the Eye)
Pyoderma Gangrenosum

Anywhere from 15-50% of all J-Pouch patients will experience pouchitis. 15-18% will experience pouchitis within the first year and about 36% will experience pouchitis within 5 years. In the tenth year, 46-48% of patients will experience pouchitis.

Not much is known about why pouchitis develops. Poor circulation, immune response, and the microbiota could be factors. Males seem to have more of a problem with pouchitis than females. Most people with pouchitis are patients with ulcerative colitis which is why many speculate that pouchitis is merely a continuation of the disease. Meaning, that surgery is not a true cure. Just an extreme version of treatment.

The treatment for pouchitis includes antibiotic therapy and antidiarrheals. It has been reported that 80% of all patients were treated successfully with this therapy and relief is found within a few days. 5-10% of patients with acute pouchitis may relapse and need to be treated again. Some studies show that probiotics can help prevent flareups or relapses.

Fistulas
Fistulas are more frequently seen several months after the procedure. Some risk factors are long-term steroid use, low oxygen in the blood, hypoalbuminemia, poor blood flow or tension/straining. One of the biggest risk factors, or possibly the biggest, is a misdiagnosis. Crohn’s patients tend to have poorer outcomes with J-Pouches. Patients with Crohn’s have a pouch failure rate of 25%. Most fistulas are treated surgically.

Anastomotic Strictures
Thickening or scarring of the connective tissues following a wound rupture at the incision site of an anastomosis may result in an anal stricture. The strictures, if severe, obstruct the anus and result in evacuation problems, pouch dilation and even bacterial overgrowth.
According to the study, the anal canal typically narrows after the J-Pouch surgery. It is believed that dilators help prevent severe strictures and the writers of the study recommend that this be done at the 6-week postoperative visit or at the time of takedown to prevent any problems.

Around 7.8-14% of patients develop strictures. A study from the Mayo Clinic finds that stapled anastomosis proves better results than hand-sewn. Their findings also show a 12% stricture rate, which is lower than previous studies found. The findings are that stapled anastomoses are preferred when performed well. Stapled pouches also result in lower complication rates than those that are hand-sewn.

Pouch Failure
It is said that about 6% of all patients who undergo the J-Pouch surgery will eventually lose their J-Pouch and require a permanent ileostomy. In a Mayo Clinic study, the risk for pouch failure at 10 years is around 9% of patients. In another study, of around 1,911 patients, the rate of pouch failure is 3.5% at 5 1/2 years. Drs. Gorgun and Remzi found that around 4.1% of patients experience pouch failure. The most common causes of pouch failure are:

Pelvic Sepsis
High Stool Volume
Crohn’s Disease
Fecal Incontinence

Cancer Risks
During the course of time, the “architecture of cells” change. Some appear to “transform” into the appearance of “colonic cells” which Drs. Gorgun and Remzi say could potentially develop into cancerous cells. But in a study of 178 patients, it was found that abnormal cells develop only in about 4.5% and no patient developed cancer or lost his or her J-Pouch because of this. The findings are that the risk of cancer or abnormal cells is very low.

In conclusion, most studies show that a majority of patients who undergo the J-Pouch surgery have excellent outcomes with a better quality of life than they dowith a diseased colon. There are many on the internet with failed J-Pouches or J-Pouch troubles (and I believe those stories are important, by the way!), I can say in all honesty that I am happy with my J-Pouch. And for 94-96% of patients who are happy with their pouches, I say those are good odds compared to a bleeding, ulcerating colon.

Sources: 
“Complications of Ileoanal Pouches.” Clinics in Colon and Rectal Surgery17.1 (2004): 43-55. Web.